Form DHCS4035 A "Nutrition Screening Form (Ages Birth - Eight)" - California

What Is Form DHCS4035 A?

This is a legal form that was released by the California Department of Health Care Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2016;
  • The latest edition provided by the California Department of Health Care Services;
  • Easy to use and ready to print;
  • Available in Spanish;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DHCS4035 A by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.

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Download Form DHCS4035 A "Nutrition Screening Form (Ages Birth - Eight)" - California

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State of California—Health and Human Services Agency
Department of Health Care Services
Child Health and Disability Prevention (CHDP) Program
What Does Your Child Eat?
(Ages Birth – Eight)
Circle the foods your child eats every day or at least 3 times per week:
Please circle Yes or No
Baby Foods
to answer the following questions:
Breast milk
Formula with Iron
Cereal with Iron
Birth to 24 months
Pureed Fruit Pureed Vegetables
Pureed Meat
Eggs
Beans
Does the child less than 1 year
Yes No
Juice
Sweetened Beverages Honey
of age eat honey/corn syrup?
Breads, Grains and Cereals
0-6 months
Whole Grain Bread
White Bread Tortilla
Sweet Bread
Breastfeeding at least 8–12 times
Cereal with Iron
Oatmeal
Bagels
Crackers
Pretzels
each 24 hours for first 3 months? Yes No
Noodle Soup
Pasta
Rice
Breastfeeding 6-8 times or more each 24 hours
Fruits and Vegetables
Yes No
for age 4-6 months?
Apple
Banana
Grapes Pear
Peach
100% Juice
Feeding formula with iron at least 20 ounces a
Strawberry
Pineapple
Orange
Cantaloupe
Melon
day?
Yes No
Bell pepper
Chili pepper Tomato
Green Salad Cucumber
6 to 9 months
Mango
Broccoli
Cabbage
Dark Green Leafy Vegetables
Eats baby cereal with iron?
Yes No
Yes No
Carrot
Green Beans Peas
Corn Potato
Sweet Potato
Eats pureed fruits and vegetables?
Milk Products
Eats pureed or ground meat, fish cooked egg
Yes No
Whole Milk
2% Milk
1% Lowfat milk
Nonfat Milk
yolk, beans, tofu?
Flavored Milk
Lactose Free Milk
Cheese Cottage Cheese
Drinks or sips from a cup?
Yes No
Yogurt
Ice Cream
9 to 12 months
Other Food Sources of Calcium
Eats mashed/chopped foods? Yes
No
Yes No
Beans
Tofu
Soy Yogurt/Milk
Green leafy vegetables
Eats foods with fingers?
Calcium Fortified 100% Juice Fortified Plant Milk (Almond, Rice)
1 to 2 years
Protein Foods
Drinks 16 ounces whole milk a day?
Yes No
Chicken/Turkey
Beef
Ham/Pork
Fish/Canned fish Eggs
Eats a variety of different foods? Yes No
Feeds himself (or herself)? Yes No
Tofu
Tacos
Meat/Beans Burritos
Peanuts/Peanut/Nut Butters
Yes No
Beans/Lentils
Spaghetti with Meatballs
Joins family meal and snack times?
Other Foods
Yes No
Drinks soda or other sweet drinks?
Hot dog
Hamburger
Pizza
French Fries Fried Chicken
Other
Chips
Cheese Puffs Candies Chocolate
Cookies
Does the child have food allergies or
Circle if baby/child uses
intolerances?
Yes No
Fluoride
Iron Drop Vitamins
Please list:_________________________
Spoon
Cup
Baby bottle
Toothbrush
Does the child play with or eat dirt, plaster, clay
Circle if baby/child drinks
or paint chips?
Yes No
Water
Soda
Sugar Sweetened Drinks
Sports Drinks
Juice
Does the child 3 years or younger eat grapes,
Circle activities your baby or child does every day
nuts, seeds, popcorn hot dogs and/or hard
Yes No
Crawling
Walking
Swinging
Rope jumping
candy?
Playing ball
Riding a tricycle/bicycle
Views TV, video games or computer more than two hours a day
Circle if baby/child receives
CalFresh (Food Stamps)
School Lunch
Head Start
WIC
Child’s name: _____________________________ Record
O
U
ONLY
FFICE
SE
#:__________
Referred for
Age: ____ yrs ____ mos Wt: _____ lbs Ht: _____ in Date: ___/___/___
identified nutrition problem?
Yes No
If yes, where: _________________________
_____________________________________
Provider initials:
_______________________
Adapted from the CHDP Programs of Orange and San Bernardino Counties
DHCS 4035 A (05/16)
State of California—Health and Human Services Agency
Department of Health Care Services
Child Health and Disability Prevention (CHDP) Program
What Does Your Child Eat?
(Ages Birth – Eight)
Circle the foods your child eats every day or at least 3 times per week:
Please circle Yes or No
Baby Foods
to answer the following questions:
Breast milk
Formula with Iron
Cereal with Iron
Birth to 24 months
Pureed Fruit Pureed Vegetables
Pureed Meat
Eggs
Beans
Does the child less than 1 year
Yes No
Juice
Sweetened Beverages Honey
of age eat honey/corn syrup?
Breads, Grains and Cereals
0-6 months
Whole Grain Bread
White Bread Tortilla
Sweet Bread
Breastfeeding at least 8–12 times
Cereal with Iron
Oatmeal
Bagels
Crackers
Pretzels
each 24 hours for first 3 months? Yes No
Noodle Soup
Pasta
Rice
Breastfeeding 6-8 times or more each 24 hours
Fruits and Vegetables
Yes No
for age 4-6 months?
Apple
Banana
Grapes Pear
Peach
100% Juice
Feeding formula with iron at least 20 ounces a
Strawberry
Pineapple
Orange
Cantaloupe
Melon
day?
Yes No
Bell pepper
Chili pepper Tomato
Green Salad Cucumber
6 to 9 months
Mango
Broccoli
Cabbage
Dark Green Leafy Vegetables
Eats baby cereal with iron?
Yes No
Yes No
Carrot
Green Beans Peas
Corn Potato
Sweet Potato
Eats pureed fruits and vegetables?
Milk Products
Eats pureed or ground meat, fish cooked egg
Yes No
Whole Milk
2% Milk
1% Lowfat milk
Nonfat Milk
yolk, beans, tofu?
Flavored Milk
Lactose Free Milk
Cheese Cottage Cheese
Drinks or sips from a cup?
Yes No
Yogurt
Ice Cream
9 to 12 months
Other Food Sources of Calcium
Eats mashed/chopped foods? Yes
No
Yes No
Beans
Tofu
Soy Yogurt/Milk
Green leafy vegetables
Eats foods with fingers?
Calcium Fortified 100% Juice Fortified Plant Milk (Almond, Rice)
1 to 2 years
Protein Foods
Drinks 16 ounces whole milk a day?
Yes No
Chicken/Turkey
Beef
Ham/Pork
Fish/Canned fish Eggs
Eats a variety of different foods? Yes No
Feeds himself (or herself)? Yes No
Tofu
Tacos
Meat/Beans Burritos
Peanuts/Peanut/Nut Butters
Yes No
Beans/Lentils
Spaghetti with Meatballs
Joins family meal and snack times?
Other Foods
Yes No
Drinks soda or other sweet drinks?
Hot dog
Hamburger
Pizza
French Fries Fried Chicken
Other
Chips
Cheese Puffs Candies Chocolate
Cookies
Does the child have food allergies or
Circle if baby/child uses
intolerances?
Yes No
Fluoride
Iron Drop Vitamins
Please list:_________________________
Spoon
Cup
Baby bottle
Toothbrush
Does the child play with or eat dirt, plaster, clay
Circle if baby/child drinks
or paint chips?
Yes No
Water
Soda
Sugar Sweetened Drinks
Sports Drinks
Juice
Does the child 3 years or younger eat grapes,
Circle activities your baby or child does every day
nuts, seeds, popcorn hot dogs and/or hard
Yes No
Crawling
Walking
Swinging
Rope jumping
candy?
Playing ball
Riding a tricycle/bicycle
Views TV, video games or computer more than two hours a day
Circle if baby/child receives
CalFresh (Food Stamps)
School Lunch
Head Start
WIC
Child’s name: _____________________________ Record
O
U
ONLY
FFICE
SE
#:__________
Referred for
Age: ____ yrs ____ mos Wt: _____ lbs Ht: _____ in Date: ___/___/___
identified nutrition problem?
Yes No
If yes, where: _________________________
_____________________________________
Provider initials:
_______________________
Adapted from the CHDP Programs of Orange and San Bernardino Counties
DHCS 4035 A (05/16)